A Systematic Literature Review of Resiliency Factors to Prevent Youth Suicide: A conversation with Dr. Sana Shahram

As we enter year 2 of the COVID-19 pandemic, many people are expressing concern about how this experience has affected our collective mental health. In particular, most of us are curious as to how we can bolster resilience among adolescents and young people in our lives.

We sat down with Dr. Sana Shahram to discuss her recent paper:  Promoting “Zest for Life”: A Systematic Literature Review of Resiliency Factors to Prevent Youth Suicide. With her team, Dr. Shahram conducted an intensive review of the literature linked to resiliency among youth.

Instead of focusing specifically on building individual levels of youth resilience, however, our conversation focused largely on a simple, but powerful, question: “How do we create systems and communities that don’t require so much resilience from our youth?”

Check out our full conversation below!


What would you say is the main takeaway from this article?

I think the main takeaway from our article is that when we're talking about an issue as complex as youth suicide and prevention, there's an urgent need to expand what that means. So, typically in this area of research, there's a lot of interest and focus on individual factors and acute intervention, which is vitally important for youth who are at risk of suicide. And yet, depending on which statistics you look at, around 40 or 50% of youth who die by suicide show no previous risk factors. So, there is a huge area of prevention that we don't know much about because we're typically focused on these downstream manifestations, and we should also be asking ourselves questions like “how do we as a community, as a system, create environments in which youth thrive and are resilient?” This way, when youth do face risks, they have resources to draw on earlier. In addition, it is important to note that those resources don't have to innately live within the youth themselves as individuals. We as a society can also take responsibility and ownership to provide those protective factors.


In your paper, you say that some of the findings validated ‘fostering resilience as primary suicide prevention among youth’. So for readers who are not familiar with the resilience literature, what is resilience? And how do researchers typically measure it?

One important finding I want to highlight is that there's quite a diversity of ways in which people understand resiliency. For the purposes of our research and our understanding, we understand resiliency to be a dynamic factor. Resiliency is not something that you either are or are not: It's in context and in response to your current situation. Very generally, we understand resilience as the ability to not only survive, but to thrive in the face of challenging circumstances, and that manifests in many ways and with many different proxy terms, such as being adaptable, strong, or having ‘grit’ so to speak. There are tons of proxies for resilience, but the concept generally implies that there is a challenge and that the response to that challenge is positive or forward-moving, rather than detrimental.

How it's measured is also very variable. Broadly, our research found that in the context of youth suicide, it is primarily measured as an individual characteristic measured through proxy terms as I mentioned. This includes things like self-determination, self-efficacy, coping skills with the implication that these things create resilience. And it's multifactorial, so I don't know that there is anyone measure that will be sufficient for resilience. But we did find that there is not a great body of literature on community-level or broader levels of resilience. And I would say that what knowledge exists around those ideas has been led by Indigenous knowledge systems and Indigenous approaches, which are inherently more concerned with the layered and relational ways that exist in our communities and in our spaces. So, while the individual focus looks at whether we can intervene on an individual level to make a single youth more resilient, and that that somehow is going to result in them being more resilient, a broader approach draws our attention to the fact that perhaps we shouldn't have systems and communities that require so much resilience from our youth. Perhaps we should have systems and communities that are resilient in and of themselves so that our youth are not being expected to survive and thrive in nonproductive environments.


In the field of psychology, resiliency is predominantly talked about, like you said, as an individual factor. I wonder if you can elaborate a bit on what it would mean if we shifted our thinking to think about resiliency as a community or societal factor?

Dr. Michael Ungar has spoken and published a lot on taking a more ecological perspective to resilience and thinking more at the systems level, where we design interventions that take into consideration these systemic factors. For example, when a youth dies by suicide, might we consider how many “touchpoints” and how many ways they entered and exited our many systems and were they getting what they needed? I'm just speculating, but I assume that there are many, many touchpoints, where they enter and exit into these systems that are created at considerable cost to taxpayers and at considerable cost to our society. And yet, the problem is not going away, so they're obviously not working. And this is not meant to be disparaging to anybody who works in this field. There's incredible resilience in those people and in those systems who try and do well by youth. And like I said before, if you were acutely at risk of suicide, of course, there needs to be individual intervention and programming.

But, one of the pitfalls at work here is that because we are in a neoliberal society because we are in economies where market justice and capitalism are at the forefront of every decision that we make, it follows that we then think that individually, we should be resilient and that individually, youth should be able to thrive. What's being missed in these conversations is that piece where, as global citizens, as people living in civil society together, we ask, what do we owe each other? Do we owe each other a social contract where we believe that the well-being of all of us is linked to each other? And if we do believe in that, what does that look like? And what does that look like when somebody is at acute risk for suicide? They need to potentially access mental health support, but is there another net that goes around that person? Is there something in place to stop that person from falling in and out of those systems when they fall short? And I would argue that no, we don't have that right now. And we don't have that, partly because our systems are set up to make us think that we are not collectively responsible, that we don't have a collective role. Our paper is the result of a local and community-led coalition of people who've come together and said “We believe we have a role. We believe we have a responsibility to each other. How do we link our hands together to create some type of net that we can wrap around the youth in our community?”

Until we actually have a shared understanding of the role that community should play, unless we agree that we need to work together, that we have some type of social contract with each other, then we will continue to create biomedical reductionist and individual-focused interventions. Those are, of course, part of the solution, but they are not adequate for truly solving the problem. Our systems, as designed, are not going to prevent individuals from being at risk. At some point, we need to decide that we don't want to keep putting bandages on a problem that's getting worse and worse. We need to decide that we want to be part of creating wellness, rather than reacting to illness.


It seems that one of the issues of focusing solely on resilience as an individual factor is that it puts the onus of responsibility on youth to recognize that they need help, and then fight to navigate a complicated and onerous mental health care network.

That is a byproduct of this misunderstanding of thinking that our healthcare system is meant to keep us healthy when, in fact, it's actually designed to react when we are sick. And that helps to explain why we have this idea that the systems are failing or that these systems are set up to fail because they were never intended to function the way that we expect them to function.

So, we have an inadequate mental health care system in a lot of ways, sure, but at the same time, what we're asking of those systems is inappropriate. Hospitals are not where this care needs to happen. Some of the care for our wellness needs to, and actually logically lives in our communities. By shifting focus we can come back to the foundation and premise of what public health really means, as opposed to letting ourselves believe that the large machine of health care in our country is going to help us make significant headway on actually creating wellness and health. It’s simply not fair to ask that systems that are set up very purposefully to respond to illness somehow also do such important prevention work when we haven't resourced that system to do so.

So the important question is how do we actually start to think of this in a more proactive way, and how do we bring the wisdom and the leadership and problem-solving capacities of communities into that conversation? There are a lot of community organizers who know how to do this work substantially better than myself, than a physician, and than executives at the Health Authority, because they've been on the ground and they've been the people who are trying to fill these gaps in a meaningful way. There are a lot of people who have important and meaningful contributions to solving these problems, such as youth themselves, but who have been left out of the conversation because they’re not perceived as “experts”.


What would you say are some of the most important ways that families or communities can foster greater resilience in youth that they might think are at risk?

So one of the things that we've done since this publication is we actually have held deliberative dialogues with youth, emerging adults, caring adults, and the people who make up our network of Advisory Council members, locally. And we've taken what's in this paper, and we've gone to community and people who have lived or living experience or who are in some way a stakeholder in this work, and we've asked them to extend and validate these findings. And what we have found is that, by and large, there's very little focus on the individual. Everything we're hearing is about issues that need to be solved at the community level, such as creating inclusive environments, creating social support systems that are not dependent on nuclear families. It’s important to note that relying solely on the nuclear family is actually historically unnatural. While we take them for granted, this idea that you should get everything you need from your immediate family is not sustainable, and its only recently that we’ve expected families to function this way. So, a lot of what we're hearing is how do you bring back that community where youth have access to many adults- so that it’s not only youth who win the family lottery that get all of their needs met. How do we create redundancy in our communities so that there are multiple check points or gatekeepers for youth that are looking out for their mental health and wellbeing?


Your article touches upon several really important individual difference factors and describes how some of these protective factors might work to protect youth. So for example, it seems like there are some really important cultural and gender influences in how some of these productive factors work. Can you describe some of these findings?

One of the main limitations of a lot of the work that is being done in this field is that these intersectionalities are not prominent. And yet, in studies that do take into account various intersectional identities, it's very obvious that these are playing a very important role. For example, we found that only 11 studies included an analysis of sex and gender differences. And yet, the research shows us that these are, of course, very important things to take into consideration on the issue of youth suicide, and the contexts that youth are living in are very much gendered and influenced by sex and gender bias and discrimination and gender identity. This is particularly important because we know that youth that has non-conforming identities experience a higher risk of death by suicide.

I hope that as these systems are shifting, as the voices of people who are oppressed are becoming more and more heard within these systems, we will become less accepting of this type of research that ignores these important factors. This research is supported by public funds, the work that we do comes from public money. And so, I think that it's very important that all of us as researchers are taking that to heart and we're taking it to heart that what we do has to matter for society, and it has to move society forward. And if we're not doing that work, then we're being disingenuous to the power and privilege that our positions offer us. The ideals that are behind the work that we do should compel us to do this work more thoughtfully and should compel us to do this work from an equity lens.

Hopefully, in 10 years, this field is going to be completely different than this scan that we just did, which is showing that, while there's important work happening, there's also a lot of important gaps that are not being addressed. Some of this work in and of itself, because of the silences that exist in it, are actually inadvertently reinforcing inequities, because they're not drawing attention to the oppression that is behind mental health outcomes for youth. What we're doing instead is pathologizing youth, we're talking about the different ways that youth need to be resilient, the different ways that youth need to change their behavior.


What are you most excited to see moving forward in this field? What kinds of questions are you particularly looking forward to the field focusing on and getting answers to?

I'm excited for the contribution that we're making to shifting the narrative and the gaze around the topic of youth suicide. I’m very excited about being a part of shifting what we're talking about, from social responsibility to systems of oppression, to the ways that the community can take a role and has the expertise and decentralizing the way that research works. I'm very excited about the fact that the work we have done to date (and this is always my barometer for success) resonates so fully with practitioners in this field, responding to the pain of working in a field with youth, where you just see the same thing happening over and over again, and you don't have an outlet. And I'm not saying that we are overnight going to solve the issue of youth suicide, but I'm excited that we are adding a different voice to the conversation, and that we are contributing to a broader lens and approach to thinking about the ways that we are implicit and complicit in creating systems of harm. And using that as fuel to see ourselves also as having agency to interrupt those systems, and to create systems that better serve ourselves, our youth, and our future, rather than doing what is sometimes easy, but is not always right.


What do you wish that more people knew about this topic?

I wish that we wouldn't see the issue of youth suicide as an individual failing, as somebody who lost their fight with mental illness. And instead, we saw it as a collective failure to create the spaces within which all of us are able to thrive. And I think that if we could start thinking about not just this issue, but all issues in that way, we could start to make more headway in addressing what the underlying issues are, rather than responding to the symptoms of these larger problems.

Most people will be familiar with the stream analogy, where there are individuals drowning in the stream and we are only focused on pulling them out once they’re in, rather than building a bridge further upstream to stop people from falling in the first place. We need to see building these metaphorical bridges as equally valuable, robust, and as equally publishable and fundable, as programs and research that focus only on the downstream effects.

Want to learn more about Dr. Shahram’s work? Check out her website here.

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